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Pediatrics International (2015) ••, ••–••
doi: 10.1111/ped.12573
Patient Report
Combination of flecainide and propranolol for congenital junctional ectopic tachycardia Tomohiko Imamura, Yuji Tanaka, Yumiko Ninomiya and Masao Yoshinaga Department of Pediatrics, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan Abstract
Congenital junctional ectopic tachycardia is a rare tachyarrhythmia with high mortality. A pharmacological approach in early infancy is regarded as the first-line therapeutic option. Pharmacologically, amiodarone alone or in combination with other drugs is the most commonly reported effective agent for congenital junctional ectopic tachycardia, but it has many adverse effects. Here we report the case of a 40-day-old infant. The clinical course suggests that combined oral flecainide and propranolol is an effective alternative therapy for early infants. Esophageal lead electrocardiography may give a clear diagnosis of junctional ectopic tachycardia.
Key words amiodarone, congenital junctional ectopic tachycardia, esophageal lead, propranolol, tachyarrhythmia.
The congenital form of junctional ectopic tachycardia (JET) usually occurs in the first 6 months of life and can present as incessant, sustained, or sporadic forms.1 It is believed to result from abnormal automaticity at, or close to, the His bundle, and may accelerate or decelerate in response to autonomic tone.2 Electrocardiography (ECG) typically shows a narrow QRS complex with variable RR intervals, and either atrioventricular dissociation or, less commonly, 1:1 ventriculoatrial (VA) conduction.2 Mortality from the congenital form of JET ranges from 35% (9/26 infants)3 in an early report to 4% (4/94 infants) in a relatively recent report.1 All four deaths in the latter report occurred at age ≤6 months, indicating that JET in early infancy is accompanied by refractoriness to treatment and high mortality.
Case report A 40-day-old infant was referred to hospital with tachycardia. The tachycardia was observed at 1 month medical check on the 29th day of life, on 12-lead ECG, which showed a wide QRS tachyarrhythmia (Fig. 1). At the first visit to hospital at 40 days of age, however, 12-lead ECG including an esophageal lead (Fig. 2) showed narrow QRS tachycardia with a P rate of 120 beats/min and a QRS rate of 220 beats/min. He was diagnosed with JET. Echocardiography showed an anatomically normal heart except for a small patent foramen ovale; left ventricular ejection fraction was 60%. I.v. ATP twice and digoxin failed to stop the tachyarrhythmia; furthermore, the QRS wave did not change at all after injection, suggesting that it was not of supraventricular origin. Combination of oral propranolol and flecainide gradually Correspondence: Yuji Tanaka, MD PhD, Department of Pediatrics, National Hospital Organization Kagoshima Medical Center, Shiroyama-cho 8-1, Kagoshima 892-0853, Japan. Email: yutanaka @kagomc2.hosp.go.jp Received 19 May 2014; revised 10 October 2014; accepted 10 November 2014.
© 2015 Japan Pediatric Society
decreased the heart rate to around 120 beats/min on the third day of admission. Atrioventricular (AV) dissociation remained and premature beats with wide QRS configuration appeared on 24 h Holter ECG on the fifth day. Mexiletine was added instead of flecainide to exclude the possibility of tachyarrhythmia of ventricular origin. The heart rate again increased to as high as 155 beats/min (Fig. 3). The combination of propranolol (1.9 mg/ kg/day) and flecainide (4.6 mg/kg/day) was re-started. He was discharged from hospital with rate control. Holter ECG 1 week after discharge showed sinus rhythm with infrequent short runs of JET and AV dissociation. Thereafter, JET recurred a few times during outpatient clinics, possibly due to a shortage of the drug in his system because of weight gain. Spontaneous resolution of JET can be expected up to the age of approximately 3 years.1 Therefore we now plan to continue combined propranolol and flecainide during infancy, on the expectation of spontaneous resolution. If the tachyarrhythmia does not resolve, radiofrequency catheter ablation or catheter cryoablation will need to be considered.
Discussion A pharmacological approach in early infancy is regarded as the first-line therapeutic option for congenital JET,4,5 although radiofrequency catheter ablation or catheter cryoablation can now be used to achieve a permanent cure at older ages.1,5 Pharmacologically, amiodarone alone or in combination with other drugs is the most commonly reported effective agent for congenital JET.1,4 In prior reports, the efficacy ratio of amiodarone has been reported to range from 60%3 to 82%,1 but i.v. and oral amiodarone treatment are associated with adverse effects, based on its electrophysiological and chemical characteristics.6–8 The present study suggests that a combination of flecainide and propranolol is an alternative effective therapy for congenital JET. The combined therapy was associated with an absence of
2
T Imamura et al.
a
b
c
Fig. 1 Twelve-lead electrocardiogram at (a) 1 month medical check (29th day), (b) first visit to hospital (40th day), and (c) outpatient clinic (72nd day). QRS morphology during JET is the same as sinus capture QRS morphology.
Fig. 2 Esophageal lead electrocardiogram (ECG): 12-lead ECG was recorded with the precordial lead V3 at the esophagus, showing clear P waves and atrioventricular dissociation.
Fig. 3 Clinical course of a 40-day-old infant. Heart rate decreased after combined oral propranolol and flecainide treatment. ATP, digoxin, and mexiletine were ineffective. © 2015 Japan Pediatric Society
adverse events, and enabled the heart rate to be controlled for 1 year. This may be the first report of a combination therapy of flecainide and propranolol for infants with congenital JET. Multidrug combined therapies have generally been thought to be preferable in prior reports, because congenital JET is resistant to many kinds of anti-arrhythmia medication.1,9 The combination of oral amiodarone and flecainide was referred to as a possible combination for postoperative JET in a prior study.9 Propranolol was selected to avoid the adverse effects of amiodarone. Thus, a combination of flecainide and propranolol may be an alternative effective therapy for congenital JET Another implication of the present case was the usefulness of an esophageal lead to recognize clear P waves, as shown in previous reports.10 The QRS morphology during JET is the same as sinus capture QRS morphology. The QRS morphology on the 29th day of life was wide; it was considered as bundle branch block due to the sustained tachyarrhythmia. A clear diagnosis with electrographic documentation of a given arrhythmia is
Congenital JET required for prescription of anti-arrhythmic drugs;2 the present study showed that an esophageal recording is also useful for the diagnosis of congenital JET.
References 1 Collins KK, Van Hare GF, Kertesz NJ et al. Pediatric nonpostoperative junctional ectopic tachycardia medical management and interventional therapies. J. Am. Coll. Cardiol. 2009; 53: 690– 97. 2 Brugada J, Blom N, Sarquella-Brugada G et al. Pharmacological and non-pharmacological therapy for arrhythmias in the pediatric population: EHRA and AEPC-Arrhythmia Working Group joint consensus statement. Europace 2013; 15: 1337–82. 3 Villain E, Vetter VL, Garcia JM et al. Evolving concepts in the management of congenital junctional ectopic tachycardia. A multicenter study. Circulation 1990; 81: 1544–59. 4 Sarubbi B, Musto B, Ducceschi V et al. Congenital junctional ectopic tachycardia in children and adolescents: A 20 year experience based study. Heart 2002; 88: 188–90.
3
5 Al-Ghamdi S, Al-Fayyadh MI, Hamilton RM. Potential new indication for ivabradine: Treatment of a patient with congenital junctional ectopic tachycardia. J. Cardiovasc. Electrophysiol. 2013; 24: 822–4. 6 Saul JP, Scott WA, Brown S et al. Intravenous amiodarone for incessant tachyarrhythmias in children: A randomized, doubleblind, antiarrhythmic drug trial. Circulation 2005; 112: 3470–77. 7 Sampson KJ, Kass RS. Anti-arrhythmic drugs. In: Brunton LL, Chabner BA, Knollmann BC (eds). Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 12th edn. McGraw-Hill, New York, 2011; 816–48. 8 Strasburger JF, Cuneo BF, Michon MM et al. Amiodarone therapy for drug-refractory fetal tachycardia. Circulation 2004; 109: 375–9. 9 Fenrich AL Jr, Perry JC, Friedman RA. Flecainide and amiodarone: Combined therapy for refractory tachyarrhythmias in infancy. J. Am. Coll. Cardiol. 1995; 25: 1195–8. 10 Blaufox AD, Warsy I, D’Souza M, Kanter R. Transesophageal electrophysiological evaluation of children with a history of supraventricular tachycardia in infancy. Pediatr. Cardiol. 2011; 32: 1110–14.
© 2015 Japan Pediatric Society
Pediatrics International (2015) ••, ••–••
doi: 10.1111/ped.12573
Patient Report
Combination of flecainide and propranolol for congenital junctional ectopic tachycardia Tomohiko Imamura, Yuji Tanaka, Yumiko Ninomiya and Masao Yoshinaga Department of Pediatrics, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan Abstract
Congenital junctional ectopic tachycardia is a rare tachyarrhythmia with high mortality. A pharmacological approach in early infancy is regarded as the first-line therapeutic option. Pharmacologically, amiodarone alone or in combination with other drugs is the most commonly reported effective agent for congenital junctional ectopic tachycardia, but it has many adverse effects. Here we report the case of a 40-day-old infant. The clinical course suggests that combined oral flecainide and propranolol is an effective alternative therapy for early infants. Esophageal lead electrocardiography may give a clear diagnosis of junctional ectopic tachycardia.
Key words amiodarone, congenital junctional ectopic tachycardia, esophageal lead, propranolol, tachyarrhythmia.
The congenital form of junctional ectopic tachycardia (JET) usually occurs in the first 6 months of life and can present as incessant, sustained, or sporadic forms.1 It is believed to result from abnormal automaticity at, or close to, the His bundle, and may accelerate or decelerate in response to autonomic tone.2 Electrocardiography (ECG) typically shows a narrow QRS complex with variable RR intervals, and either atrioventricular dissociation or, less commonly, 1:1 ventriculoatrial (VA) conduction.2 Mortality from the congenital form of JET ranges from 35% (9/26 infants)3 in an early report to 4% (4/94 infants) in a relatively recent report.1 All four deaths in the latter report occurred at age ≤6 months, indicating that JET in early infancy is accompanied by refractoriness to treatment and high mortality.
Case report A 40-day-old infant was referred to hospital with tachycardia. The tachycardia was observed at 1 month medical check on the 29th day of life, on 12-lead ECG, which showed a wide QRS tachyarrhythmia (Fig. 1). At the first visit to hospital at 40 days of age, however, 12-lead ECG including an esophageal lead (Fig. 2) showed narrow QRS tachycardia with a P rate of 120 beats/min and a QRS rate of 220 beats/min. He was diagnosed with JET. Echocardiography showed an anatomically normal heart except for a small patent foramen ovale; left ventricular ejection fraction was 60%. I.v. ATP twice and digoxin failed to stop the tachyarrhythmia; furthermore, the QRS wave did not change at all after injection, suggesting that it was not of supraventricular origin. Combination of oral propranolol and flecainide gradually Correspondence: Yuji Tanaka, MD PhD, Department of Pediatrics, National Hospital Organization Kagoshima Medical Center, Shiroyama-cho 8-1, Kagoshima 892-0853, Japan. Email: yutanaka @kagomc2.hosp.go.jp Received 19 May 2014; revised 10 October 2014; accepted 10 November 2014.
© 2015 Japan Pediatric Society
decreased the heart rate to around 120 beats/min on the third day of admission. Atrioventricular (AV) dissociation remained and premature beats with wide QRS configuration appeared on 24 h Holter ECG on the fifth day. Mexiletine was added instead of flecainide to exclude the possibility of tachyarrhythmia of ventricular origin. The heart rate again increased to as high as 155 beats/min (Fig. 3). The combination of propranolol (1.9 mg/ kg/day) and flecainide (4.6 mg/kg/day) was re-started. He was discharged from hospital with rate control. Holter ECG 1 week after discharge showed sinus rhythm with infrequent short runs of JET and AV dissociation. Thereafter, JET recurred a few times during outpatient clinics, possibly due to a shortage of the drug in his system because of weight gain. Spontaneous resolution of JET can be expected up to the age of approximately 3 years.1 Therefore we now plan to continue combined propranolol and flecainide during infancy, on the expectation of spontaneous resolution. If the tachyarrhythmia does not resolve, radiofrequency catheter ablation or catheter cryoablation will need to be considered.
Discussion A pharmacological approach in early infancy is regarded as the first-line therapeutic option for congenital JET,4,5 although radiofrequency catheter ablation or catheter cryoablation can now be used to achieve a permanent cure at older ages.1,5 Pharmacologically, amiodarone alone or in combination with other drugs is the most commonly reported effective agent for congenital JET.1,4 In prior reports, the efficacy ratio of amiodarone has been reported to range from 60%3 to 82%,1 but i.v. and oral amiodarone treatment are associated with adverse effects, based on its electrophysiological and chemical characteristics.6–8 The present study suggests that a combination of flecainide and propranolol is an alternative effective therapy for congenital JET. The combined therapy was associated with an absence of
2
T Imamura et al.
a
b
c
Fig. 1 Twelve-lead electrocardiogram at (a) 1 month medical check (29th day), (b) first visit to hospital (40th day), and (c) outpatient clinic (72nd day). QRS morphology during JET is the same as sinus capture QRS morphology.
Fig. 2 Esophageal lead electrocardiogram (ECG): 12-lead ECG was recorded with the precordial lead V3 at the esophagus, showing clear P waves and atrioventricular dissociation.
Fig. 3 Clinical course of a 40-day-old infant. Heart rate decreased after combined oral propranolol and flecainide treatment. ATP, digoxin, and mexiletine were ineffective. © 2015 Japan Pediatric Society
adverse events, and enabled the heart rate to be controlled for 1 year. This may be the first report of a combination therapy of flecainide and propranolol for infants with congenital JET. Multidrug combined therapies have generally been thought to be preferable in prior reports, because congenital JET is resistant to many kinds of anti-arrhythmia medication.1,9 The combination of oral amiodarone and flecainide was referred to as a possible combination for postoperative JET in a prior study.9 Propranolol was selected to avoid the adverse effects of amiodarone. Thus, a combination of flecainide and propranolol may be an alternative effective therapy for congenital JET Another implication of the present case was the usefulness of an esophageal lead to recognize clear P waves, as shown in previous reports.10 The QRS morphology during JET is the same as sinus capture QRS morphology. The QRS morphology on the 29th day of life was wide; it was considered as bundle branch block due to the sustained tachyarrhythmia. A clear diagnosis with electrographic documentation of a given arrhythmia is
Congenital JET required for prescription of anti-arrhythmic drugs;2 the present study showed that an esophageal recording is also useful for the diagnosis of congenital JET.
References 1 Collins KK, Van Hare GF, Kertesz NJ et al. Pediatric nonpostoperative junctional ectopic tachycardia medical management and interventional therapies. J. Am. Coll. Cardiol. 2009; 53: 690– 97. 2 Brugada J, Blom N, Sarquella-Brugada G et al. Pharmacological and non-pharmacological therapy for arrhythmias in the pediatric population: EHRA and AEPC-Arrhythmia Working Group joint consensus statement. Europace 2013; 15: 1337–82. 3 Villain E, Vetter VL, Garcia JM et al. Evolving concepts in the management of congenital junctional ectopic tachycardia. A multicenter study. Circulation 1990; 81: 1544–59. 4 Sarubbi B, Musto B, Ducceschi V et al. Congenital junctional ectopic tachycardia in children and adolescents: A 20 year experience based study. Heart 2002; 88: 188–90.
3
5 Al-Ghamdi S, Al-Fayyadh MI, Hamilton RM. Potential new indication for ivabradine: Treatment of a patient with congenital junctional ectopic tachycardia. J. Cardiovasc. Electrophysiol. 2013; 24: 822–4. 6 Saul JP, Scott WA, Brown S et al. Intravenous amiodarone for incessant tachyarrhythmias in children: A randomized, doubleblind, antiarrhythmic drug trial. Circulation 2005; 112: 3470–77. 7 Sampson KJ, Kass RS. Anti-arrhythmic drugs. In: Brunton LL, Chabner BA, Knollmann BC (eds). Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 12th edn. McGraw-Hill, New York, 2011; 816–48. 8 Strasburger JF, Cuneo BF, Michon MM et al. Amiodarone therapy for drug-refractory fetal tachycardia. Circulation 2004; 109: 375–9. 9 Fenrich AL Jr, Perry JC, Friedman RA. Flecainide and amiodarone: Combined therapy for refractory tachyarrhythmias in infancy. J. Am. Coll. Cardiol. 1995; 25: 1195–8. 10 Blaufox AD, Warsy I, D’Souza M, Kanter R. Transesophageal electrophysiological evaluation of children with a history of supraventricular tachycardia in infancy. Pediatr. Cardiol. 2011; 32: 1110–14.
© 2015 Japan Pediatric Society
